Antibiotic Guideline For Obstetrics And Gynaecological Infections:GOI

Published On 2016-08-18 08:20 GMT   |   Update On 2016-08-18 08:20 GMT

In 2016 National Centre For Disease Control, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India came out with National Treatment Guidelines for Antimicrobial Use in Infectious Diseases.


 

Following are major recommendations for Obstetrics And Gynaecological Infections:


 

 

  • Fluoroquinolones are contraindicated in 1st trimester.

  • Cotrimoxazole is contraindicated in 1st trimester.

  • Doxycycline is not recommended in nursing mothers. If need to administer doxycycline discontinuation of nursing may be contemplated.


 

 
























InfectionsLikely organismPrimary treatment (presumptive antibiotics)Alternate treatmentRemarks
Asymptomatic Bacteriuria > 1,00,000 cfu/ ml of bacteria of same species in 2 urine cultures obtained 2-7 days apart.

Treat as per sensitivity result for 7 days.
Nitrofurantoin 100 mg Oral, BD for 7 days

or Amoxicillin 500 mg Oral BD x 7-10 days .
Oral cephalosporins, TMP-SMX or TMP aloneScreen in 1st trimester. Can cause pylonephritis in upto 25% of all pregnant women. 30 % Chance of recurrence after empirical therapy 1. Few direct effects, uterine hypo perfusion due to maternal anemia dehydration, may cause fetal cerebral hypo perfusion.

2. LBW, prematurity,premature labour, hypertension, preeclampsia, maternal anemia, and amnionitis. Need to document pyuria (Pus cells > 10/HPF)
Group B streptococcal Disease, Prophylaxis and TreatmentGroup B StreptococciIV Penicillin G 5 million units. (Loading dose) then 2.5 -3 million units IV QID until delivery.

or

Ampicillin 2 gm IV ( Loading dose) then 1 gm QID until delivery
Cefazolin 2 gm IV (Loading Dose) and then 1 gm TID

Clindamycin 900 mg IV TID or vancomycin IV or teicoplanin for penicillin allergy
Prevalance very low so the prophylaxis may be required only on culture documented report Associated with high risk of pre-term labour,still birth,neonatal sepsis

 

 

 










ChorioamnionitisGroup B streptococcus, Gram negative bacilli, chlamydiae, ureaplasma and anaerobes, usually PolymicrobialClindamycin/ vancomycin/ teicoplanin and cefoperazone-sulbactum

If patient is not in sepsis then IV Ampicillin
Preterm Birth, 9-11% death rate in preterm infant’s unfavourable neurologic outcome, lesser risk to term infants.

































Septic abortionBacteroides, Prevotella bivius, Group B, Group A Streptococcus,

Enterobactereaceae, C. trachomatis, Clostridium perfringens.
Ampicillin 500 mg QID +Metronidazole 500mg IV TDS if patient has not taken any prior antibiotic (start antibiotic after
sending cultures) If patient has been partially treated with antibiotics, send blood cultures and start PiperacillinTazobactam or Cefoperazonesulbactam till the sensitivity report is available.
Ceftriaxone 2g IV

OD
Endomyometritis

and Septic Pelvic

Vein Phlebitis
Bacteroides, Prevotella bivius, Group B, Group A Streptococcus, Enterobactereaceae, C. trachomatis, Clostridium perfringensSame as above.
Obstetric Sepsis during pregnancyGroup A beta-haemolytic Streptococcus, E.coli, anaerobes.If patient is in shock and blood culture reports are pending, then start

Piperacillin-Tazobactam

or

Cefoperazone-sulbactam till the sensitivity report is available and modify as per the report. If patient has only fever, with no features of severe sepsis start amoxicillin clavulanate oral 625TDS/IV 1.2 gm TDS Or

Ceftriaxone 2gm IV OD+ Metronidazole 500mg IV TDS +/-gentamicin 7mg/kg/day OD

if admission needed. MRSA cover may be required if suspected or colonized (Vancomycin/ Teicoplanin)
Obstetric Sepsis following pregnancyS. pyogenes,

E. coli,

S. aureus

S. pneumoniae, Meticillin-resistant

S. aureus (MRSA),

C. septicum & Morganella morganii.
Same as aboveSources of sepsis outside Genital tract Mastitis UTI Pneumonia Skin and soft tissue (IV site, surgical site, drain site etc.)













SyphillisRefer to STD program guidelines












Tuberculosis in pregnancySimilar to NON PREGNANT population with some exceptions (see comment and chapter 8)Please refer RNTCP guideline

WHO has advocated that, all the first line drugs are safe in pregnancy and can be used except streptomycin. SM causes significant ototoxicity to the fetus (Pyrazinamide not recommended by US FDA)

1. Mother and baby should stay together and the baby should continue to breastfeed.

2. Pyridoxine supplementation is recommended for all pregnant or breastfeeding women taking isoniazid as well as to neonate who are being breast fed by mothers taking INH.
Very small chance of transmission of infection to fetus.

Late diagnosis can predispose to LBW, prematurity.









VIRAL INFECTIONS (NO ANTIBIOTICS TO BE GIVEN)













Influenza In pregnancy (seasonal And H1N1)

The best preventive strategy is administration of single dose of killed vaccine.
Oseltamivir 75 mg Oral BD for 5 daysNebulization with Zanamvir respules (2) 5 mg each, BD for 5 days1. Tendency for severe including premature labor &delivery.

2. Treatment should begin within 48 hrs of onset of symptoms.

3. Higher doses commonly used in non pregnant population (150 mg) are not recommended in pregnancy due to safety concerns.

4. Chemoprophylaxis can be used in significant exposures.

5. Live (nasal Vaccine) is contraindicated in pregnancy.
Direct fetal infection rare Preterm delivery and pregnancy loss.












Varicella >20 wks of gestation, presenting within 24 hours of the onset of the rash,

Aciclovir 800mg Oral 5 times a day IV acyclovir recommended for the treatment of severe complications,

> 24 hrs from the onset of rash, antivirals are not found to be useful.
VZIG should be offered to susceptible women < 10 days of the exposure. VZIG has no role in treatment once the rash appears.

The dose of VZIG is 125 units / 10kg not exceeding 625 units, IM.
Chickenpox during pregnancy does not justify termination without prior prenatal diagnosis as only.

A minority of fetuses infected develop fetal

varicella syndrome.









PARASITIC INFECTIONS












Acute Toxoplasmosis

in pregnancy
<18 weeks gestation at diagnosis-

Spiramycin 1 gm Oral qid until 16-18 weeks/Pyrimathamine + sulphadizine. Alternate every two weeks–

If PCR Positive -

>18 weeks gestation and documented fetal infection by positive amniotic fluid PCR.

Pyremethamine 50 mg Oral BD x 2 days then 50 mg OD +

Sulphadiazine 75 mg/kg Oral x 1 dose then 50mg/kg bd

+

Folinic Acid (10-20 mg Oral daily) for minimum of 4 weeks or for duration of pregnancy.










Malaria In pregnancy As per national program









GENITAL TRACT INFECTIONS
















































CandidiasisCandida speciesFluconazole oral 150 mg single dose For milder cases-

Intravaginal agents as creams or suppositories clotrimazole, miconazole, nystatin. Intravaginal azoles, single dose to 7-14 days.
Non-pregnant- If recurrent candidiasis, (4 or more episodes/year) 6 months suppressive treatment with fluconazole 150 mg oral once a week or clotrimazole vaginal suppositories 500 mg once a week.
Bacterial vaginosisPolymicrobialMetronidazole500mg Oral BD x 7 days

Or metronidazole vaginal gel 1 HS x 5 days

Or Tinidazole 2 g orally ODx 3 days

Or 2% Clindamycin Vaginal cream 5 gm HS x 5 days
Treat the partner.
TrichimoniasisTrichomonas vaginalisMetronidazole 2 gm single dose or 500 mg Oral BD X 7 days or

Tinidazole 2 gm Oral single doseFor treatment failure – retreat with Metronidazole 500 mg Oral BD X 7 Days, if 2nd failure Metronidazole 2 gm Oral OD X 3- 5 days
Treat sexual partner with metronidazole 2 gm single dose
Cervicitis /Urethritis Mucopurulent gonoccocalPolymicrobialCeftriaxone 250 mg IM Single dose + Azithromycin 1 gm single dose OR Doxycycline 100mg BD x 7 day
Pelvic Inflammatory Disease (Salpingitis & tubo-ovarian abscess)S. aureus, Enterobacteriacae, gonococci, gardenellaOutpatient treatment

Ceftriaxone 250 mg IM/IV single dose plus +/- Metronidazole 500 mg BD x 14 days Plus Doxycycline 100 mg BD x 14 Days

Inpatient Treatment Clindamycin +ceftriaxone till patient admitted then change to OPD treatment
Drainage of tuboovarian abscess wherever indicated Evaluate and treat sex partner
Mastitis without abscessS. aureusAmoxycillin clavulunate/Cephalexin 500 mg QID/ OR Ceftriaxone 2 gm OD OR MRSA- based on sensitivities Add Clindamycin 300 QID or

Vancomycin I gm IV 12 hourly /teicoplanin 12mg/kg IV 12 hourly x 3 doses followed by 6 once daily IV
Mastitis with abscessDrainage with antibiotic cover for MRSA

Clindamycin 300 QID or

Vancomycin 15mg/kg IV 12 hourly (maximum 1gm 12 hourly)/teicoplanin 12mg/kg IV 12 hourly x 3 doses followed by 6 mg once daily IV


You can read the full Guideline by clicking on the following link :


http://www.ncdc.gov.in/writereaddata/linkimages/AMR_guideline7001495889.pdf

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